M C2000189 0796 c.

Rescuers must be alert for clues that imply that the car turned over (1) Roof dents (2) Debris (3) Deformity of roof posts d. There are more lethal injuries in this form of accident because there is a greater likelihood of occupants being ejected. e. Occupants ejected from the car are 25 times as likely to be killed. 6. Occupant restraint systems a. Restrained occupants are much more likely to survive because they are protected from much of the impact inside the auto and are restrained from being ejected from the auto. b. These occupants are still susceptible to certain injuries if the lap belt is around the abdomen instead of the pelvis. (1) The body tends to fold together like a clasp-knife. (figure 14) (2) The head may be thrown forward into the steering wheel or dashboard. c. (3) Facial, head, or neck injuries are common. Abdominal injuries occur if the lap belt is positioned improperly. d. The compression forces that are produced when a body is suddenly folded about the waist may injure the abdomen or the lumbar spine. e. The three-point restraint or cross-chest lap belt secures the body much better than does a lap belt alone. (figure 15) (1) The chest and pelvis are restrained, so life threatening injuries are less common. (2) The head is not restrained, and therefor the neck is still subject to stresses that may cause: (a) Fractures (b) Dislocations (c) Spinal cord injuries. (3) Clavicular fractures are common. NOTE: Clavicular fractures are the most common fractures in MVC. 7 pounds of pressure is all it takes to fracture a clavicle.

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M C2301001 0796 (4) Internal organ damage may still occur due to organ movement inside the body. f. Passive restraints, like air bags, will reduce injuries in victims of MVCs in most but not all situations. (figure 15) (1) Air bags are designed to inflate from the center of the steering wheel and the dashboard to protect the front-seat occupants in case of a frontal deceleration accident. (2) When the air bags are functioning properly, they cushion the head and chest at the instant of impact. (a) This is very effective initially in decreasing injury to the face, neck, and chest. (b) Air bags deflate immediately (1/100 th of a second), so they protect only for one impact, not the 2nd or 3rd impact. (3) Air bags do not prevent down and under movement, so drivers who extend may still impact with their legs and suffer: (a) Leg injuries (b) Pelvis injuries (c) Abdominal injuries NOTE: Air bags are most effective when utilized with chest and lap belts. (4) An important clue to look for in patients with suspected internal injuries is a damaged steering wheel (a) This clue is commonly missed because the deflated air bag covers the steering wheel. (b) A quick lift and look under the air bag should be a part of the routine examination of the steering wheel. 7. Tractor accidents a. One third of all farming accident fatalalities involve tractors. b. The center of gravity of tractors is high, making tractors easy to overturn or flip. (figure 16) c. The majority of fatal accidents are due to the tractor turning over and crushing the driver. (1) 85 % of overturns are to the side; these are less likely to pin the driver because they have the opportunity to jump to safety. (2) Rear overturns are more likely to entrap and crush the driver because there is almost no opportunity to jump free. d. The primary mechanism of injury is the crush injury. 15

M C2000189 0796 (1) The severity depends on the part of the anatomy that is involved. (2) Additional mechanisms of injuries are chemical burns from: (a) Gasoline (b) Diesel fuel (c) Hydraulic fluid (d) Battery acid (3) Thermal burns from hot engine parts or ignited fuel are also common. e. Management consists of scene stabilization followed quickly by the primary survey and resuscitation. f. The following questions are used in scene stabilization: (1) Is the engine off? (2) Are the rear wheels locked or blocked? (3) What is the fuel situation? (4) What is the hazard of fire? g. The tractor must be stabilized by other rescuers while the primary survey is being conducted. (1) The center of gravity must be identified before any attempt is made to lift the tractor. (a) The center of gravity of the two wheel drive tractor is located approximately 10 inches above and 24 inches in front of the rear axel. (b) The center of gravity of a four wheel drive tractor is closer to the midline of the machine.. (2) Because tractors usually overturn on soft ground and their center of gravity is tricky to determine, great care must be taken during lifting to avoid a second crush injury. (3) Due to the weight of the tractor and the length of time (usually prolonged) pinned, anticipate serious injuries. (a) Often, the patient will go into profound shock as the compressing weight of the tractor is removed. (b) Rapid, safe management of tractor accidents requires special exercises in lifting heavy machinery as well as good trauma management.

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M C2301001 0796 8. Small vehicle crashes a. Other small vehicles that fall into the motion injury category include the: (1) Motorcycle (2) All terrain vehicle (3) Snowmobile b. The operators of these vehicles are not encased within them, and, of course, there are no restraining devices. c. When the operator is subjected to the classic head-on, lateral-impact, rear-end, or rollover collisions their only form of protection is: (1) Evasive maneuvering (2) Helmet usage (3) Protective clothing: (a) Leather clothes (b) Helmet (c) Gloves (d) Boots d. Motorcycles: (1) It is extremely important for motorcycle riders to wear helmets. (2) Helmets help prevent head injury. Note: Head injuries cause 75 % of all motorcycle deaths. (3) Helmets do not provide any protection for the C-spine. (4) Injuries depend on the part of the anatomy subjected to kinetic energy. (5) Due to the lack of protective encasement, there is a higher frequency of: (figure 17) (a) Head injury (b) Spine injury (c) Extremity injury

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M C2000189 0796 (6) Important clues to look for when assessing scene include: (a) Deformity to motorcycle (b) Distance of skid (c) Deformity of stationary objects or cars (7) A high degree of suspicion for load and go injuries should be present. e. All-Terrain Vehicles (ATVs) (1) The ATV is one of the newer additions to the arsenal of trauma weapons. (2) The ATV was designed as a vehicle to traverse rough terrain, used initially by ranchers, hunters, and farmers. (3) Careless recreational misuse has resulted in an ever increasing morbidity and mortality from accidents, sadly, frequently among the very young. The two basic designs are either threewheeled or four-wheeled. (a) The four-wheel design affords reasonable stability and handling. (b) The three-wheel design has a high center of gravity and is very prone to rollover when turned sharply. (5) The three most common mechanisms of injury are: (a) Vehicle rollover (b) Fall-off of rider or passenger (c) Forward deceleration of rider from vehicle impact with stationary object. (6) The injuries produced depend upon the mechanism of injury and the part of the anatomy that is impacted. (7) The most frequent injuries include: (a) Fractures ( above and below the diaphragm). 1Clavicles 2Sternum 3Ribs (b) Head (c) Spinal

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M C2301001 0796 f. Snowmobiles (1) Snowmobiles are used for both as recreational and utility vehicles. (2) The snowmobile has a low ground clearance and a low center of gravity. (3) The injuries common to this vehicle are very similar to those that occur with the ATV. (a) Turnovers are somewhat more common, and since the vehicle is usually heavier than the ATV, crush injuries are seen more frequently. (b) The injury pattern depends on the part of the anatomy that is directly involved with the crash. (c) A common injury with the snowmobile is the hangman or clothes line injury that results from running under wire fences. (figure 19) (d) Have a high degree of suspicion for occult cervical spine injuries and potential airway compromise. g. Pedestrian Injuries (1) The pedestrian hit by a car almost always suffers severe internal injuries as well as fractures. (figure 20) (2) The mass of the automobile is so large that high speed is not necessary to impart high-energy transfer. (3) There are two mechanisms of injury: (a) Bumper of car striking the body. (b) Body hitting ground or other object. (4) Injuries that can occur are: (a) Adult - bilateral femur fractures and any secondary injury. (b) Children - pelvis injuries with secondary head injuries. (c) Be prepared for fractures, internal injuries, and head injuries.

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M C2000189 0796 OBJECTIVE 2: Given a MOI of rapid vertical deceleration, a simulated patient, and a list of injuries, select the injuries associated with the patient and MOI IAW cited references.

B. Rapid Vertical Deceleration 1. The mechanism for falls is vertical deceleration 2. The types of injuries sustained depend upon three factors that you may identify and relay to medical direction. These factors are: a. Distance of fall b. Anatomical area impacted c. Surface struck 3. The primary groups of people involved are: a. Adults b. Children under the age of five (5) (1) Usually involve males. (2) Occur mostly in summer months in urban high-rise multiple occupant dwellings. 4. Predisposing factors include: a. Poor supervision b. Defective railings c. Curiosity associated with the age group of children d. Drug and alcohol use by adults

5. Common injuries: a. Head injuries are common in young children because the head is the heaviest part of the body. b. Adults have a more controlled fall, usually landing on feet, buttocks, and outstretched hands. (Lovers leap) c. The lovers leap fall may result in the following injuries: (1) Fractures of feet and/or legs (2) Hip injuries/pelvic injuries 20

M C2301001 0796 (3) Axial loading to the lumbar and cervical spine (4) Vertical deceleration forces to the internal organs (5) Colless fractures of the wrist d. The greater the height, the greater the potential for injury. e. Surface density (concrete versus sawdust) and irregularity (gym floor versus staircase) also influence the potential for severity of injury. OBJECTIVE 3: Given a simulated patient with a penetrating injury, an MOI, and a list of injuries, select the injuries that match the MOI IAW cited references.

C. Projectile Penetration 1. Numerous objects are capable of producing penetrating injuries. 2. These range from the industrial saw blade that breaks off at an extremely high rotations per minute (rpm) rate to the foreign body hurled by a lawn mower. 3. The most common forms of penetrating wounds in the American society come from knifes and guns.

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M C2000189 0796 4. Knife wound severity depends on the anatomical area penetrated, blade length, and angle of penetration. NOTE: An upper abdominal stab wound may cause intrathoracic organ injury and stab wounds below the 4th intercostal space may have penetrated the abdomen. 5. If the blade is still inside the body do not remove it unless it poses an airway problem. 6. Most penetration wounds inflicted by firearms are due to: a. Handguns b. Rifles c. Shotguns 7. Important factors to obtain, if possible, is the type of: a. Weapon b. Caliber c. Distance from which the weapon was fired USEFUL BALLISTIC INFORMATION Caliber: The internal diameter of the barrel, and this corresponds to the ammunition used for the particular weapon.

Rifling:

A series of spiral grooves in the interior surface of the barrel of some weapons. Rifling imparts a stabilizing spin to the missile.

Ammunition:

Case, primer, powder, and slug.

Bullet Construction: Usually solid lead alloy and may have a full or partial copper or steel jacket. The shape may by rounded, flat, conical, or pointed. The bullet may be soft or hollow (for expansion or fragmentation).

8. Wound ballistics a. Because the kinetic energy produced by a projectile is mostly dependent upon velocity, weapons are classified as high velocity or low velocity. (1) High velocity weapons - velocities > 2,000 ft/sec 22

M C2301001 0796 (a) 50 cal (b) M16's (c) 9mm handgun (d) 10mm handgun (2) Low velocity weapons - velocities < 2,000 ft/sec (a) 45mm handgun (b) 22mm handgun (c) 357 magnum handgun (d) Shotgun NOTE: Kinetic Energy = mass x velocity2 (3) Low velocity weapons are much less destructive than high velocity weapons. (4) High velocity weapons carry an additional factor of hydrostatic pressure, which can increase the injury. b. Factors that contribute to tissue damage include: (1) Missile size - the larger the bullet, the more resistance and the larger the permanent track. (2) Missile deformity - hollow point and soft nose flatten out on impact, resulting in a larger surface area involved. (3) Semijacket - the jacket expands and adds to surface area. (4) Tumbling - tumbling of the missile causes a wider path of destruction. (5) Yaw - the missile can oscillate vertically and horizontally about its axis, resulting in a larger surface area presenting to the tissue. c. The wound consists of three parts: (1) Entry wound (2) Exit wound - not all entry wounds will have exit wounds, and on occasion there may be multiple exits due to fragmentation of bone and missile; generally, the exit wound is larger and has ragged edges. (3) Internal wound 23

M C2000189 0796 (a) Low-velocity projectiles inflict damage primarily by damaging tissue that the missile contacts. (b) High-velocity projectiles inflict damage by tissue contact and transfer of kinetic energy to surrounding tissues. 1Shock waves 2Temporary cavity, which is 30 to 40 times the bullets diameter and creates immense tissue pressures. 3Pulsation of the temporary cavity, which creates pressure changes in the adjacent tissue. d. Generally damage done is proportional to tissue density. e. Highly dense organs such as bone, muscle, and liver sustain more damage than less dense organs such as lungs. NOTE: Once a bullet enters a body, its trajectory will not always be in a straight line. f. Any patient with a missile penetration of the head, thorax, or abdomen should be transported immediately. g. Personnel who have been shot while wearing a flak vest should be managed with caution; be alert for: (1) Cardiac contusion (2) Pulmonary contusion (3) Other organ contusion h. In shotgun wounds, injury is determined by kinetic energy at impact that is influenced by: (1) Powder (2) Size of pellets (3) Choke of muzzle (4) Distance to target i. Velocity and kinetic energy dissipates rapidly as distance is traveled. j. At 40 yards the velocity is one-half the initial muzzle velocity. OBJECTIVE 4: Given a list of factors for blast injury and a list of definitions, match the definition to the factor IAW cited references.

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M C2301001 0796 D. Blast Injuries 1. Blast injuries in this country occur primarily in industrial settings such as grain elevator and gas fume explosions. 2. The threat of blast injury due to terrorist activity is also a new concern in America. 3. The mechanism of injury by blast/explosion is due to three factors: a. Primary - initial air blast b. Secondary - victim being struck by material propelled by the blast force c. Tertiary - body being thrown and impacting on ground or other object 4. Injuries due to the primary air blast are almost exclusive to the air-containing organs. a. Auditory system usually involves ruptured tympanic membranes. b. Lung injuries include: (1) Pneumothorax (2) Parenchymal hemorrhage (3) Alveolar rupture c. Gastrointestinal tract injuries may vary from mild intestinal and stomach contusions to frank rupture 5. Injuries sustained by the secondary factors are similar to those previously discussed. 6. Tertiary injuries are much the same as to be expected from being ejected from an automobile.

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